Thursday, October 23, 2014

HISTORY: THE SPANISH FLU OF 1918: THE PAST PANDEMIC TO REACH TEXAS

VON ORMY—This month Ebola virus reached Texas and media attention focused on whether Texas and the rest of the world was prepared to address a pandemic.The last major pandemic to strike Texas was the Spanish Flu in 1918.This outbreak infected 500 million people worldwide, killing between 50 and 100 million.The Spanish Flu was unusual in that it was most destructive among the young and healthy — a group that typically is affect least.

Monday, September 30 started off much the same as previous days at Camp Travis, Texas, only five miles northeast from downtown San Antonio – hot and dusty. Soon, however, it had become clear that September 30 was going to be markedly different; 51 of the camp’s 34,127 men fell sick with influenza that day. Anticipating far more patients than these, the camp’s medical officers departed from their normal routine and spent the afternoon supervising crews of enlistees as they cleaned up and outfitted nine buildings as emergency hospitals, with an eye for future expansion if necessary. Three days later, as the number of cases at the camp continued to increase, Brigadier General George H. Estes ordered the strict quarantine of Camp Travis. Neither soldiers nor civilian contractors working at the two installations were allowed to leave, and no one was allowed to enter the camp except on official business.

Meanwhile, in San Antonio, city health officer Dr. William Anthony King believed that there was little over which to worry. The affliction making the rounds, he announced, was nothing more than ordinary grippe, though perhaps more easily spread than past versions. Still, there were already several hundred cases of influenza reported in the city. Fort Sam Houston, within city limits, had 234 cases, and the Red Cross nurses’ quarters there was full of sick nurses unable to care for soldiers. King decided that discretion was the better part of valor. Rather than take chances, King asked owners and managers of public entertainment venues to keep their ventilation systems running and to bar entry of anyone exhibiting symptoms of illness. He would, King added, appoint deputies to enforce these measures if necessary.

Epidemic conditions across Texas were quickly growing worse. On October 7, United States Surgeon General Rupert Blue issued a circular to state authorities urging them to consider public gathering bans and closure orders if epidemic conditions in their regions warranted it. Following on that advice, as well as that of Texas Health Officer W. B. Collins, Acting Governor Reinzi Johnston issued his own statement to local health officers across the state to “give their careful consideration the recommendation of the Federal and State Health authorities with a view to discontinue public assemblages, closing public schools and places of public amusement in localities where the prevalence and severity of this disease renders such a course of action necessary and advisable.”

In San Antonio, King quickly called for a meeting with city and local military officials to discuss the influenza situation. At Camp Travis and Fort Sam Houston, the epidemics were severe but appeared to be peaking. Each camp was under quarantine to reduce the chances of spreading influenza to the local civilian population. In the city, physicians were reporting an average of one hundred or so cases daily, but thus far there had been no civilian deaths. Influenza was not a reportable disease in Texas, however, and health authorities had to rely on voluntary reporting of physicians. After consideration, King declined to impose bans on public gatherings, recommending instead that people avoid crowds and that schools send sick children home. “If sensible precautions are taken, there is no cause for alarm, especially as long as the warm weather continues,” he told the public. Again, he said this was but ordinary grippe. In fact, King and the Board of Health believed that the city’s epidemic was on the decline and that further Board meetings were thus no longer necessary.

For the next several days, all appeared quiet on the epidemic front. The local newspaper, the San Antonio Express, turned its attention towards the conditions in the local army camps, and published nary a word on civilian cases of influenza. The lull did not last for long, however. On October 16, King, the Board of Health, and other authorities met once again to discuss the epidemic. Billing the move as a precautionary one, the Board of Health suddenly voted to close all schools, churches, lodges, and theaters, and to ban public gatherings effective the next day. The Board asked residents to stay home as much as possible; children were expressly prohibited from gathering on playgrounds during their impromptu vacation.

The closure order came very late, right as San Antonio’s epidemic was reaching its peak. Suddenly, San Antonians began to take their epidemic very seriously. On October 19, physicians, perhaps spurred by the closure order, reported a total of 700 influenza cases for the previous 24-hour period, a marked increase from the previous daily tallies. King now admitted that the epidemic was far from being under control. At pains to explain why San Antonio’s influenza situation now seemed so dire, the health officer accused those with mild forms of the disease with spreading it by not taking strict personal precautions. Medical personnel were overwhelmed with cases. About half the medical staff at Fort Sam Houston were themselves sick with influenza and had to be replaced with infantrymen. At Robert G. Green Memorial Hospital for San Antonio’s and Bexar County’s indigent, 18 student nurses tended to 140 influenza patients, since the 12 regular nurses there were ill. King declared that it might be necessary to convert schools to makeshift emergency hospitals if the epidemic grew much worse.

On October 23, King announced that the influenza epidemic was waning; the previous two day’s reports showed 306 cases and 399, respectively. “The situation in every way is much better,” King said, “but we will not lift the quarantine until the disease is stamped out.”1 Several days later, with 256 cases reported for the day, King told residents that influenza was now firmly under control. By the end of the month, the number of new cases had dropped to 80. King believed the danger had passed, and announced that the closure order and gathering ban might be removed within a few days if the situation continued to improve.

When city officials met informally on November 1, however, they deemed it too risky to lift the public health orders. Several present believed that conditions were still too serious, and that a premature removal of the bans could cause a resurgence of the epidemic. One health department physician stated that a few more days would show a decided improvement in the influenza situation. The group thus decided to revisit the idea at its next meeting, scheduled for Tuesday, November 4. Over the interceding weekend, however, the case tallies did not decline, averaging slightly over 200 per day. With the news, few expected health authorities to lift the closure order. King believed that the epidemic was running its course, but argued that it would do so more quickly if residents observed health and hygiene regulations more stringently.

King and his colleagues paid close attention to the influenza situation over the next several days, with an eye to lifting the closure order as soon as they saw safe to do so. At noon on Saturday, November 9, King and the Board of Health met to review the week’s influenza reports. Only 47 new cases were reported, a significant drop from previous tallies. The group decided that the time had finally come for San Antonio daily life to return to normal. Effective at one minute past midnight on Monday, November 11, the city’s schoolchildren would return to their classrooms, theaters and movie houses would reopen their doors, and public gatherings could once again take place. Entertainment venues immediately went about preparing their businesses for a flow of patrons. The Majestic planned on opening with “Two Sweethearts,” a vaudeville act. The Grand prepared a double-feature for moviegoers: “The Devil’s Double” starring William Hart, and “The Cook” with comedic actor Fatty Arbuckle. At the Princess, eager patrons could see Charlie Chaplin play a doughboy recruit eager to show his heroism in “Shoulder Arms.” Little did the city know that Monday would soon become Armistice Day, giving residents even more reason to celebrate.

As San Antonio reopened, health authorities took stock of the past weeks. Between September 30 and November 7, city physicians reported 7,391 cases of influenza and nearly 500 resultant deaths to the health department. King thanked the public for their patience and their cooperation in making San Antonio’s battle with epidemic influenza a success. In fact, according to these figures, the city had experienced a rather high case fatality rate of 6.7 percent. And the war with influenza was not yet over.

The rest of November passed without too much trouble. After three weeks off, students returned to their classrooms to discover that they would be required to go to school on the Friday and Saturday following Thanksgiving in order to prepare for the usual pre-Christmas round of exams. As one reporter put it, “many a sidelong glance was cast from windows to the sunlit outside” as children sat at their desks during what was the year before a holiday break. Shortly thereafter, however, the epidemic began to spike once again. By the first days of December, health officials were working non-stop to find care for influenza victims. King announced that he might have to place San Antonio under another round of restrictions if the situation did not improve soon.

He did not give the city or the epidemic much time to respond. The next day, December 5, King met with the Board of Health, Mayor Bell, school officials, the Bexar County health officer, medical officers from Fort Sam Houston and Camp Travis, and United States Public Health Service representatives. Surveying the rising tide of influenza, the group decided to implement a second closure order in San Antonio. Effective the next morning, theaters, movie houses, and other entertainment venues were to close. Authorities were still undecided as to whether churches, schools, and large public events such as the upcoming Britain Day Celebration should be included, and postponed that decision until the Superintendent of Schools Charles Meek could investigate and report back on the influenza conditions in the schools. Meanwhile, in a separate meeting, the city commission finally passed an ordinance making influenza a mandatory reportable disease.

The next day, King stated that he did not wish for the second closure order to be unfairly applied to only certain businesses; if the situation demanded it, he would close additional places of gathering. Likewise, if the situation improved, theaters and movie houses would be allowed to reopen – again – the following week. In the meantime, he asked for the cooperation of the military in prohibiting dances, and the support of residents in taking the epidemic seriously. Not fully understanding the nature of influenza epidemics, King assumed that the recent spike in cases could only be the result of carelessness on the part of San Antonians. “The people have treated lightly the warnings of the health department and the various learned physicians,” he decried, “and have been led by random reasonings of their own.” Yet a few lines later, he admitted that the city had lifted its previous round of closures too soon.

On December 9, the Board of Health met again to consider whether the closure order should be extended to other gathering places as well. With 527 cases reported for the previous two days, the Board decided that more stringent measures were indeed necessary. Effective the morning of December 10, all schools (public, private, and parochial) and churches were ordered closed, and all public and private dances, lectures, conventions, and banquets prohibited. Several private schools asked that they be allowed to remain open, given their small class size and well-ventilated buildings. The Board refused all such requests.

Once again, San Antonio acted late; the second bout with influenza had already reached a peak on December 7. Still, health authorities were even more determined to stamp out the epidemic once and for all. When several pool halls remained open – their owners claimed that they had not been notified of the closure order – King directed Police Chief Frederick Lancaster to shut them immediately. Department store managers announced that they were eager to comply with the Board of Health’s request that they prevent crowding in their shops and to stagger their business hours. To ensure that they held true to their word, King arranged for bands of residents to volunteer to line up in front of stores during peak hours to ensure that customers did not crowd inside. Theater and movie house employees, upset that stores were allowed to remain open while they were put out of work once more, requested that they be allowed to volunteer for the anti-crowding patrols. King denied their request, possibly to prevent their potentially over-zealous enforcement of the new rules.

The number of influenza cases slowly declined, and within a week King told the public that the closure orders could be removed in a few day’s time if the trend continued. He also directed physicians to report the names and addresses of influenza cases so that health authorities could keep better track of them and to placard infected homes.Theater managers and workers were not so easily placated, however. Upset at what they considered to be their unfair treatment by the Board of Health, they sought a injunction relief from the Thirty-Seventh District Court as a way of testing the legal authority of the city to issue closure orders. On December 21, however, before the case could get off the ground, the San Antonio Board of Health voted to rescind the closure order, effective immediately, with schools to reopen after the Christmas holidays. By agreement between both sides, the case was dismissed. Mayor Bell, angered by the incident, testily responded to the theater lobby, letting them know that the city would impose a third closure order if necessary. “The Health Department cannot afford to place dollars above human lives,” he stated publicly, “and I regret that any business man in the city would assume this attitude.” King echoed the sentiments. “If we do [issue another closure order] I want the theatrical people to understand that we will not be deterred by their complaints. They are, in fact, the only ones who have complained,” the health officer said.

Conclusion

Perhaps the most interesting aspect of San Antonio’s epidemic is how late the Board of Health was to take action. When the Board issued closure orders in October and December, the moves coincided exactly with the two fall peaks of the city’s epidemic. Ideally, the time to implement closure orders and gathering bans would have been several weeks before those peaks. Undoubtedly this late action was a result of having poor tracking data, as influenza was not made a mandatory reportable disease in the city until December 7, 1918. Relying on voluntary reporting of cases, King and the Board of Health had imperfect information on which to base their decision to close San Antonio’s public gathering places.

Overall, between the start of the epidemic in September and the end of January of 1919, San Antonio physicians reported 12,367 cases of influenza to the health department. Of these cases, 881 people died, a case fatality rate of 7.1%.27 These numbers might not be accurate, however. According to the results of a door-to-door survey conducted by United States Public Health Service officers W. H. Frost and Edgar Sydenstricker, San Antonio’s actual incidence rate – the number of people who contracted influenza – was a whopping 535 per 1,000 residents. 28 That would peg the real number of San Antonio influenza cases at something closer to 86,000, and the case fatality rate at approximately 1.0%. The city’s epidemic death rate was approximately 550 per 100,000 people, about average for the nation as a whole.

Parts of this article are courtesy of the University of Michigan Library .